Issue 2347, Nov. 29, 2016

Last week, the U.S. Justice Department (DOJ) and a bipartisan group of state attorneys started court proceedings to block the $48 billion mega-merger between Anthem and Cigna. The merger, if allowed to proceed, would reduce competition and increase health plan market power, compromising patients’ access to care and negatively impacting the quality and affordability of health care across the country.

Many of the physicians that I know are LGBT friendly, but patients don’t know that and are very afraid that they’re being judged...Physicians often don’t recognize that they are not being inclusive or sensitive to LGBT people's concerns, so there is often a disconnect and that’s where more education would be helpful." Read More

California's doctors aren't just health care and medical experts. They're also community leaders, philanthropists, entrepreneurs and policymakers dedicated to ensuring that patients receive quality health care at an affordable cost. #CMAdocs showcases California physicians leading the charge to help their communities thrive. Share your story or celebrate a deserving colleague today!

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(Photo: Courtesy of John Gibbins / Union-Tribune)

Quotable: Condolences from across the region and nation are streaming in for the family and colleagues of Dr. Richard Butcher, the family practitioner venerated for his work with the poor and disadvantaged. Read More

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1. Court proceedings begin in Anthem-Cigna mega-merger suit

Last week, the U.S. Justice Department (DOJ) and a bipartisan group of state attorneys started court proceedings to block the $48 billion mega-merger between Anthem and Cigna. The merger, if allowed to proceed, would reduce competition and increase health plan market power, compromising patients’ access to care and negatively impacting the quality and affordability of health care across the country.

“The California Medical Association has opposed the Anthem-Cigna mega-merger since day one because it will hurt patients and increase health care costs,” said California Medical Association (CMA) President Ruth E. Haskins, M.D. “Limiting market competition would compel insurers to contract with fewer physicians, resulting in higher premiums and longer wait times for referrals – not to mention forcing many patients to pay more to see out-of-network doctors.”

Seventy-one percent of the nation’s metropolitan areas already lack competitive commercial health insurance markets. A merger between Anthem-Cigna would further diminish competition in 121 metro areas throughout the 14 states where Anthem is licensed to provide commercial coverage.

“When it comes to scope, coverage and quality of health care, what do you trust – the clinical judgment of trained physicians or the corporate policy of insurance companies?” asked Dr. Haskins. “California’s health insurance markets need more competition to ensure that patients receive quality and affordable care.”

In March 2016, a CMA-backed survey of California physicians revealed an overwhelming 85 percent opposed the Anthem-Cigna merger. Out of the 989 physicians surveyed from practices across the state, the majority expressed that the health insurer union could narrow physician networks (82 percent), force physicians to provide fewer services (90 percent) and pressure physicians into refraining from aggressive patient advocacy (75 percent).

The DOJ’s lawsuit is supported by 11 states – including California, New York and Connecticut – and the District of Columbia.

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2. Seminar: What does MACRA mean for your practice? Find out 12/10 in San Francisco

The American Medical Association (AMA) and the California Medical Association are hosting a free educational seminar to help physicians understand how the Medicare Access and CHIP Reauthorization Act (MACRA) will impact their practices.

The seminar, Saturday, December 10, from 9– 11:00 a.m. at the San Francisco Marriott Marquis, will also cover what medical practices need to do to be a part of the quality payment program.

Physicians can also visit CMA's MACRA resource center at www.cmanet.org/macra to better understand the payment reforms and access resources to help with the transition. The center is a one-stop-shop with tools, checklists and information from CMA, CMS, AMA and national specialty society clinical data registries. CMA will add an updated summary and materials, including additional webinars, to the resource center in the coming weeks.

* The California Medical Association/Institute for Medical Quality (CMA/IMQ) is accredited by the Accreditation Council on Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The California Medical Association/Institute for Medical Quality (CMA/IMQ) designates this live internet activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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The U.S. Surgeon General issued a report last week calling drug and alcohol addiction a public health crisis that is underappreciated and undertreated. Nearly 21 million Americans – more than the number of people who have all cancers combined – suffer from substance use disorders.

Surgeon General Vivek Murthy, M.D., said he hopes that his report on drug and alcohol will galvanize work on the issue much like the groundswell of action that followed the Surgeon General's landmark report on smoking some 50 years ago.

“Alcohol and drug addiction take an enormous toll on individuals, families, and communities,” said Dr. Murthy, “Most Americans know someone who has been touched by an alcohol or a drug use disorder. Yet 90 percent of people with a substance use disorder are not getting treatment. That has to change.”

The report, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health, marks the first time a U.S. Surgeon General has dedicated a report to substance misuse and related disorders. The report addresses alcohol, illicit drugs and prescription drug misuse, with chapters dedicated to neurobiology, prevention, treatment, recovery, health systems integration and recommendations for the future. It provides an in-depth look at the science of substance use disorders and addiction, calls for a cultural shift in the way Americans talk about the issue. The report also recommends actions we can take to prevent and treat these conditions, and promote recovery.

One of the findings of this report is that substance use disorder treatment in the United States remains largely separate from the rest of health care and serves only a fraction of those in need of treatment. One in seven people in the U.S. is expected to develop a substance use disorder at some point in their lives. Yet only 1 in 10 of those suffering from these disorders receives treatment.

“The Surgeon General’s Report on Alcohol, Drugs, and Health provides a roadmap for working together to move our efforts forward,” said Kana Enomoto, principal deputy administrator for the Substance Abuse and Mental Health Services Administration. “I hope all who read it will be inspired to take action to stem the rising tide of this public health crisis and reduce the impact of substance misuse and addiction on individuals, communities, and our nation.”

The report makes clear that substance misuse – which includes use of a substance in any way that can cause harm to oneself or others – is an underappreciated but critical public health challenge that can lead to substance use disorders, such as addiction. The report also points out that adolescents and young adults are particularly at risk.

“It’s time to change how we view addiction,” said Dr. Murthy. “Not as a moral failing but as a chronic illness that must be treated with skill, urgency and compassion. The way we address this crisis is a test for America.”

The California Medical Association (CMA), along with the American Medical Women’s Association and the American Civil Liberties Union (ACLU), sent a letter to Prometric, one of the largest test development and delivery networks in the country, asking it to ensure that pregnant and breastfeeding test takers have consistent access to reasonable accommodations during their exams.

“It has come to our attention that Prometric does not consistently provide appropriate accommodations to candidates who are pregnant or breastfeeding at the time they are taking exams at Prometric facilities,” said the letter. “These accommodations are medically necessary and denying them can lead to adverse medical consequences for test takers."

Testing accommodations are necessary for many people who are pregnant or breastfeeding because the default conditions for administering their exams generally do not meet their needs. Rules restrict what candidates may bring into the test site, there is no access to a private location in which to express breast milk (other than the public restroom) and the existing breaks may, depending on an individual candidate’s circumstances, be insufficient for dealing with conditions associated with pregnancy, including the necessary expression of breast milk.

“Denying these accommodations also violates California law, which strictly prohibits business establishments from discriminating on the basis of sex. As defined in the law, discriminating on the basis of 'sex' includes discrimination on the basis of pregnancy and pregnancy-related medical conditions, such as breastfeeding.”

Prometric operates a multinational network of testing centers, with thousands of sites in 160 countries. The company administers countless health care certification and entrance exams, such as the Medical College Admission Test (MCAT).

Because the company already provides accommodations for candidates with disabilities, CMA believes extending accommodations to candidates who are pregnant or breastfeeding should be a straightforward endeavor. “Accommodations should be made available to pregnant or lactating test takers on the same terms as they are offered to others with medical conditions or disabilities,” the letter said.

Numerous professional organizations and the California legislature have established specific guidelines for ensuring appropriate accommodations for pregnancy and breastfeeding. California has enacted strong legal protections that require reasonable accommodations for people who are pregnant, nursing or experiencing pregnancy-related medical conditions.

The Ninth Circuit Court of Appeals heard oral arguments earlier this month in a patient privacy case involving law enforcement access to Oregon’s Prescription Drug Monitoring Program (PDMP). The California Medical Association (CMA) joined the American Medical Association and other western state medical associations in 2015 to file an amicus brief with the appeals court challenging the authority of the U.S. Drug Enforcement Administration (DEA) to obtain patients' private prescription records without a court order.

In this case, the DEA sought patient-specific information from Oregon’s PDMP through the use of a federal administrative subpoena, which does not involve judicial review or a showing of probable cause. The Oregon PDMP, however, refused to comply with the DEA’s subpoena on the ground that doing so would violate Oregon state law, which requires a court order based on probable cause before patient data in the PDMP can be disclosed to any federal, state or local law enforcement agency.

A coalition of plaintiffs that include Oregon’s PDMP, the American Civil Liberties Union (ACLU), patients and physicians filed a lawsuit in federal court against the DEA challenging the use of administrative subpoenas to access PDMP information. The plaintiffs argued that information in the PDMP is protected under the Fourth Amendment of the U.S. Constitution and that the DEA must show probable cause and obtain a warrant prior to accessing such information.

The federal trial court sided with the State of Oregon and concluded that the Fourth Amendment prohibits the DEA from issuing administrative subpoenas for the database records. The court held that patients have an expectation of privacy in their prescription information contained in the PDMP stating that it “is difficult to conceive of information that is more private or more deserving of Fourth Amendment protections.” The DEA appealed this ruling to the Ninth Circuit Court of Appeals, whose jurisdiction includes California.

The brief filed by the medical associations urges the court to recognize the profound interests that this case places at issue in the areas of patient privacy and the integrity of the patient-physician relationship. The protection of patient privacy “is essential for a patient-physician relationship built on trust … so that patients will seek care and so that doctors may provide the most efficacious health care for the patient’s benefit,” the brief states. It advocates for the strongest possible protections for patient prescription data collected by state prescription drug monitoring programs so that data is used by doctors and pharmacists for responsible treatment and prescription practices and to protect public health and safety, not for the enhancement of federal law enforcement without stringent legal safeguards.

Click here to read the medical associations’ brief. A decision from the Ninth Circuit is expected in early 2017.

According to the CDC, at least 2 million people each year in the U.S. acquire serious infections with bacteria that are resistant to one or more of the antibiotics designed to treat those infections. At least 23,000 people die each year as a direct result of these antibiotic-resistant infections.

Antibiotic stewardship programs are designed to coordinate interventions to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy and route of administration.

At the interim meeting of the American Medical Association (AMA) House of Delegates last weekend in Florida, delegates from the California Medical Association and more than 170 state and specialty medical societies from across the country affirmed their commitment to health insurance coverage for all Americans.

“Using a comprehensive policy framework that has been refined over the past two decades, AMA will actively engage the incoming Trump Administration and Congress in discussions on the future direction of health care," said Andrew W. Gurman, M.D., AMA president. "AMA remains committed to improving health insurance coverage so that patients receive timely, high-quality care, preventive services, medications and other necessary treatments."

AMA has long advocated for health insurance coverage for all Americans, as well as pluralism, freedom of choice, freedom of practice and universal access for patients. The same core principles and priorities will guide future AMA advocacy efforts regarding the Affordable Care Act.

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